Welcome to the MUS Webinar Controlled Drugs Gosport Then and Now - PowerPoint PPT Presentation

MEDICINES USE AND SAFETY WEBINAR OCTOBER 2019 • Welcome to the MUS Webinar – Controlled Drugs – Gosport Then and Now • The webinar itself will start at 1pm. Shortly before 1pm the SPS webinar host will be doing sound checks so bear with us if you hear this more than once! • To join the audio call 0203 478 5289 Access code: 952 783 486. • The webinar will be recorded and both recording and slide set will be available on the SPS website – under Networks (you need to be logged onto the SPS site to access the recording) • If you want to make a comment or ask a question – please use the “chat” function. (You need to choose to direct your question to “All Participants” from the drop down box) • The presenters will answer questions at the end of the presentation The way we contact you is changing so please register on our website: www.sps.nhs.uk; update your profile with your network choices from the Medicines Use & Safety Networks list; tick the box to opt in to receive updates and save your profile. www.sps.nhs.uk 1

Upcoming MUS Events WEBINARS : Medicine Safety – 2020 and Beyond 13 November Sabina Khanom (NHSE/I), Nicola Wake (MUSN) 11 December Medicines Governance Do Once Programme Tracy Rogers, Jo Jenkins, Amanda Cooper FACE TO FACE EVENTS (held in London) 23 October MUSN (Fully booked) 27 November Older People Network www.sps.nhs.uk 2

The Gosport Independent Panel Report jon.hayhurst@nhs.net NHS England and NHS Improvement

Gosport War Memorial Hospital • Gosport is a town on a peninsula in Hampshire • Gosport and Portsmouth are just a few hundred yards apart by ferry • Separation is 15miles by road • The hospital opened in 1923 and has developed as a community hospital 4 | 4 | The Gosport Independent Panel Report

Gosport War Memorial Hospital • Community hospitals vary considerably, as they have adapted to the needs of their local populations • In community hospitals, medical care is normally led by GPs in liaison with consultants, nursing and other health professionals as required • The pride of local people and their attachment to Gosport War Memorial Hospital was illustrated by the successful campaign to save it from closure in the 1990s and indeed its redevelopment in 1994 5 | 5 | The Gosport Independent Panel Report

Concerns about care • Concerns about the care of older patients in Gosport War Memorial Hospital had been the subject of scrutiny for many years and numerous investigations had taken place • In 2013, the Department of Health published a clinical audit which had taken place in 2003 by Professor Richard Baker covering the period 1988-2000 • Norman Lamb established the Gosport Independent Panel, under the chairmanship of Bishop James Jones, to review the documentary evidence 6 | 6 | The Gosport Independent Panel Report

Concerns raised in 1991 • In February 1991 staff at Gosport expressed concern over the prescribing and administration of drugs with syringe drivers. A number of nurses raised concerns about the prescribing of drugs, in particular diamorphine. • “A Staff Nurse at the hospital rang the local branch convenor of the Royal College of Nursing to express concerns shared by other members of the night staff over the use of diamorphine and syringe drivers.” 7 | 7 | The Gosport Independent Panel Report

The concerns 1. Not all patients given diamorphine have pain. No other forms of analgesia are considered, and the ‘sliding scale’ for analgesia is never 2. used. 3. The drug regime is used indiscriminately, each patients individual needs are not considered, that oral and rectal treatment is never considered. 4. That patients deaths are sometimes hastened unnecessarily. 5. The use of syringe driver on commencing diamorphine prohibits trained staff from adjusting dose to suit patients needs. 6. That too high a degree of unresponsiveness from the patients was sought at times. 7. That sedative drugs such as Thioridazine would sometimes be more appropriate. That diamorphine was prescribed prior to such procedures such as catheterization – where 8. diazepam would be just as effective. 9. That not all staff views were considered before a decision was made to start patients on diamorphine – it was suggested that weekly ‘case conference’ sessions could be held to decide on patients complete care. 10. That other similar units did not use diamorphine as extensively. 8 | 8 | The Gosport Independent Panel Report

Culture Raising the concerns in the first place was a brave act given the culture at the hospital. There is documented evidence that the nurses felt ostracised as a result. After an unsatisfactory meeting at which the nurses were faced with an intimidating array of other staff, evidence showed that the nurses were dismissively told to take any future concerns up directly with the doctor whose practice they had reason to challenge. 9 | 9 | The Gosport Independent Panel Report

Gosport Independent Panel • It is over 27 year since nurses at the hospital first voiced their concerns • The report of the Gosport Independent Panel found (in 2018) that the concerns were valid 10 | 10 | The Gosport Independent Panel Report

Gosport Independent Panel • It is over 27 year since nurses at the hospital first voiced their concerns • The report of the Gosport Independent Panel found (in 2018) that the concerns were valid  The lives of over 450 people (and probably another 200 as well) were shortened as a direct result of the pattern of prescribing and administering opioids that had become the norm at the hospital 11 | 11 | The Gosport Independent Panel Report

Patient stories “For example, the daughter of one patient discovered that a syringe driver had been inserted. She queried this because she knew her father wasn’t in pain and didn’t need it, but ward staff were dismissive, telling her she was not a nurse and that they were the professionals. She was furious and called her father’s GP, who arranged for the syringe driver to be taken out and for her father to come home.” 12 | 12 | The Gosport Independent Panel Report

Patient stories “Another patient was admitted for respite care but deteriorated and became confused during his stay. Staff asked permission to give him diamorphine, but his daughter refused, as he was not in pain. However, her mother later agreed, and he was started on diamorphine by syringe driver. He died the same day”. 13 | 13 | The Gosport Independent Panel Report

Patient stories “A man admitted for dementia was started on a diamorphine syringe driver. Staff asked his son for permission and he gave it but felt there was no explanation of what it meant to be given diamorphine. The dose was doubled, and his father died five days later. His son felt that the diamorphine effectively killed him”. 14 | 14 | The Gosport Independent Panel Report

The panel’s findings • Finding One: Opioid usage without appropriate clinical indication • Finding Two: Anticipatory prescribing with a wide range of doses • Finding Three: Continuous opioid usage for patients admitted for rehabilitation or respite care • Finding Four: Continuous opioids started at inappropriately high doses • Finding Five: Opioids combined with other drugs in high doses • Finding Six: Few patients survived long after starting continuous opioids • Finding Seven: Prescription and administration of drugs contravened guidelines • Finding Eight: Occurrence and certification of deaths 15 | 15 | The Gosport Independent Panel Report

What exactly happened? • Between 1987 and 2001, there was a huge increase in the use of diamorphine without any apparent indication for the patients that received it • At the same time there was a huge increase in the number of deaths, and in the number of deaths being recorded as due to ‘bronchopneumonia’ • The patients involved were not admitted for end of life care but often for rehabilitation or respite care 16 | 16 | The Gosport Independent Panel Report

Opioids without indication 17 | 17 | The Gosport Independent Panel Report

Deaths at the hospital 18 | 18 | The Gosport Independent Panel Report

Deaths due to bronchopneumonia 19 | 19 | The Gosport Independent Panel Report

Correlation 20 | 20 | The Gosport Independent Panel Report

How did this happen? The practice of anticipatory prescribing, and of administering certain drugs in circumstances and doses beyond what would have been indicated or justified clinically, involved the consultants, the clinical assistant, the nurses and the pharmacists. Many people were prescribed and administered drugs that were not clinically indicated, in quantities sufficient to shorten their lives. 21 | 21 | The Gosport Independent Panel Report

Why did this happen? Anticipatory prescribing was used on the basis that medication might become necessary at a time when the doctor covering a ward was unable or unwilling to attend in order to prescribe it. A pattern of clinical judgements were then being made that patients were close to death, regardless of the purpose of their admission or the plan in place. The documents show that these judgements were often not justified clinically and did not take into account patients’ or families’ views. 22 | 22 | The Gosport Independent Panel Report